F0554

D

Failure to Follow Self-Administration of Medication Policy for Bedside Medications

Riverside, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its policy and procedure for self-administration of medications for one resident. The resident was admitted with multiple serious conditions, including acute and chronic respiratory failure, lumbar radiculopathy, chronic pain syndrome, acetonuria, and was receiving palliative care. A History and Physical indicated the resident had capacity to make decisions. A Quarterly Risk Assessment for Self-Administration of Medications dated February 3, 2026, documented that the resident requested to self-administer medications, that nursing recommended the resident could self-administer, and specifically listed only docusate sodium 100 mg as a bowel care medication to be self-administered as needed.

During observation, surveyors found multiple medications stored at the resident’s bedside in two zippered cosmetic bags, including acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, docusate sodium 250 mg, potassium 99 mg, and Hair Skin and Nails vitamins. The resident stated she kept these medications at the bedside and took them as needed, reporting daily use of docusate sodium 250 mg for constipation and as-needed use of the other medications, including ZzzQuil Pure Zzzs Melatonin Gummies for sleep. The resident also stated she was not required to keep a record of, or inform nursing staff about, the medications she took.

Interviews with LVNs, the RN, and the DON showed inconsistency between facility practice and the self-administration policy. Multiple nurses stated residents were not allowed to keep medications at the bedside or self-administer unless there was a physician’s order and a completed self-administration assessment, and that residents who self-administer must inform nursing so doses can be documented on the MAR. The DON confirmed there was a self-administration assessment for the resident but acknowledged that the medications found at the bedside were not on the assessment and not ordered by the physician, and confirmed that acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, potassium 99 mg, and Hair Skin and Nails vitamins were not included on the Quarterly Risk Assessment. The facility’s written policy required IDT evaluation of appropriateness, safe and secure storage, determination and instruction regarding documentation responsibility, and removal of any unauthorized bedside medications, which was not followed in this case.